Orthopedic Coding Alert

Question: We-ve been getting denials for navigation code 20985. Should we be doing something differently?

North Carolina Subscriber

Answer: CPT 2008 replaced computer-assisted navigation codes 0054T-0056T with +20985-+20987 (Computer-assisted surgical navigational procedure for musculoskeletal procedures -). But unfortunately, many payers still consider these procedures investigational and won't cover them.

Example: BlueCross BlueShield North Carolina states that it "does not provide coverage for computer-assisted surgical navigational orthopedic procedures of the pelvis and appendicular skeleton. It is considered investigational. BCBSNC does not provide coverage for investigational services." This policy is typical of many payers, although you may find that some payers have not yet updated their policies to refer to 20985-20987 rather than 0054T-0056T.

Tip: For payers that don't cover these services, you may choose to have the patient sign a form similar to an advance beneficiary notice (ABN). Be sure the patient understands he-ll have to cover the cost if his insurer doesn't pay.

If you appeal the denial, be sure you explain medical necessity for the procedure and include literature proving efficacy of computer-assisted navigation.

Medicare has assigned 3.97 RVUs to 20985, which equates to $130.15 in North Carolina for facility or nonfacility settings, according to the Medicare physician fee schedule (http://www.cms.hhs.gov/pfslookup/). So convincing payers the procedures are not investigational could result in a significant boost in reimbursement.